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Search for:
Term Life Insurance quote
Step
1
of
3
33%
Name
*
First
Last
Primary Phone
*
Secondary Phone
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
Month
Day
Year
Gender
*
Male
Female
Height (ft/in)
*
Weight (lbs)
*
Tabacco/Nicotine last use
*
Current User (1 pack a day
Current user (more than 1 pack a day)
Used in the last year
Last use over 1 year
Last use over 2 years
Last use over 3 years
Last use over 4 years
Last use over 5 years
Never
How you would define your Health Class
*
Not sure
Best Class - excellent health condition
Preferred -very good health condition
Standard Plus - good with minor problems
Standard - Standard health condition, minor issues
Rated - Have serious issues with my health
Coverage Amount
*
Please enter a number from
50000
to
2000000
.
Please enter amount you would like to be insured e.g. $75000, $100,000, $750,000, $1,000,000
Period to be insured
*
10-year Term
15-year Term
20-year Term
25-yea Term
30-year Term
Other (please put info in notes)
You have filled quick quote information
Would you like answer several more questions to get a more accurate quote?
*
Yes
No
This will lead to more questions
Where do your cholesterol levels fall?
Cholesterol - <=220 and HDL ratio - <=5.0
Cholesterol - <=250 and HDL ratio - <=6.0
Cholesterol - <=280 and HDL ratio - <=6.5
Cholesterol - <=300 and HDL ratio - <=7.5
Cholesterol - >300 and HDL ratio - >7.5
Unknown
Where does your normal Blood Pressure reading fall?
Blood Pressure <= 135/85
Blood Pressure <= 140/85
Blood Pressure <= 140/90
Blood Pressure <= 145/90
Blood Pressure <= 150/90
Blood Pressure <= 155/90
Blood Pressure >155/90
Unknown
Have any of your parents or siblings been diagnosed or died from Diabetes, Cancer or any Cardiovascular disorder prior to the age of 60?
Yes
No
Have you ever been diagnosed, treated, prescribed medicine or advised to seek treatment by a member of the medical profession of any of the following?
Respiratory Disorders
Heart and Circulatory Disorders/Conditions
Chronic Renal Failure, Cirrhosis, AIDS, HIV, or AIDS Related Complex (ARC)
Depression or Emotional Disorders/Conditions
Diabetes
Cancer
Other
Other:
Have you ever been treated or advised to seek treatment for alcohol or drug use?
Yes
No
Have you used any recreational drugs during the past 5 years?
Yes
No
Are you taking any prescription medications or do you have any other health conditions, not already mentioned?
Yes
No
Do you have any felony charges pending or are you on Probation for a Felony?
Yes
No
Are you currently participating in any Aviation or Scuba related activities?
Private Pilot or Student Pilot
Scuba Diving more than 100 feet in depth
Do you currently, or do you have any plans to participate in any of the following activities?
Hang Gliding
Power Boat racing > 100mph
Automobile or Motorcycle racing
Mountain Climbing >= 13,000 feet
Other extreme sports (bungee jumping, canyoing, street luge)
How many moving violations have you had in the last 3 years?
Less than or equal to 2 in the last 3 years
No more than 3 in the last 3 years
No more than 4 in the last 3 years
More than 4 in the last 3 years
Have you ever had a DUI or reckless Driving conviction?
Yes
No
Have you filed for bankruptcy in the past 7 years?
Yes
No
